Article

Lateral subvastus approach with osteotomy of the tibial tubercle for total knee replacement: A two-year prospective, randomised, blinded controlled trial

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Abstract

The lateral subvastus approach combined with an osteotomy of the tibial tubercle is a recognised, but rarely used approach for total knee replacement (TKR). A total of 32 patients undergoing primary TKR was randomised into two groups, in one of which the lateral subvastus approach combined with a tibial tubercle osteotomy and in the other the medial parapatellar approach were used. The patients were assessed radiologically and clinically using measurement of the range of movement, a visual analogue patient satisfaction score, the Western Ontario McMasters University Osteoarthritis Index and the American Knee Society score. Four patients were lost to the complete follow-up at two years. At two years there were no significant differences between the groups in any of the parameters for clinical outcome. In the lateral approach group there was one complication due to displacement of the tibial tubercle osteotomy and two osteotomies took more than six months to unite. In the medial approach group, one patient had a partial tear of the quadriceps. There was a significantly greater incidence of lateral patellar subluxation in the medial approach group (3 of 12) compared with the lateral approach group (0 of 16) (p = 0.034), but without any apparent clinical detriment. We conclude that the lateral approach with tibial tubercle osteotomy is a safe technique with an outcome comparable with that of the medial parapatellar approach for TKR, but the increased surgical time and its specific complications do not support its routine use. It would seem to be more appropriate to reserve this technique for patients in whom problems with patellar tracking are anticipated.

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... A technique to improve exposure is the tibial tubercle osteotomy. While the tibial tubercle osteotomy was developed for revision knee arthroplasty, some difficult primary knee arthroplasty cases benefit from this extensile approach (4)(5)(6)(7)(8)(9)(10). Tibial tubercle osteotomy has also been used for the treatment of patella-femoral tracking pathology (11). ...
... Its use, however, is not well documented in trauma. It is well documented that the tibial tubercle osteotomy increases exposure to the articular surface of the knee (5,6,8,14). However there has only been one article to the best of our knowledge describing the technique in the setting of trauma(12). ...
... He used an anterior approach to the knee with elevation and proximal retraction of the whole extensor mechanism. The technique described in this paper has already been described in arthroplasty literature (6). It employs the lateral sub-vastus approach and a step cut tibial tubercle osteotomy from lateral to medial with a broad surface of bone keeping the medial periosteum intact. ...
Article
Methods: A cadaveric study using 8 knee specimens was conducted using a lateral subvastus approach to the knee. Standardised pictures were taken of the exposure, the tibial tubercle osteotomy was performed and pictures were taken of the new exposed area. These images were compared using a computer program that calculated the area of exposure before and after tibial tubercle osteotomy and the results analysed. The technique was then used in a case series of 6 different complex knee fractures including three distal femoral, one periprosthetic distal femur and two tibial plateau fractures. The outcomes of these patients were followed clinically and radiologically. Results: All specimens in the cadaveric study demonstrated an increase in area of exposure after the TTO with a mean increase of 148%. All tibial tubercle osteotomies performed in the trauma case series were united by 6 months without complication. Conclusions: Tibial tubercle osteotomy is a recognised technique for improving exposure to the knee. This has been demonstrated in a cadaveric study and in a case series of six complex fractures around the knee. If performed properly, this technique can be extended to appropriate trauma cases with good results.
... Approaching TKA from the lateral side (e.g., lateral parapatellar and minimally invasive lateral approaches) gained popularity as an alternative approach that provided good surgical exposure and recovery in patients with a valgus deformity [1,3,[21][22][23][24][25][26][27][28][29][30][31][32][33][34]. Because of the difficulty in mobilizing the patella medially, many authors have employed a tibial tuberosity osteotomy (TTO) to ease exposure [1,22,23,26,28,31,35,36]; however, the approach is still feasible without this [1,7,29,30,32,34,37]. Despite the more difficult intraoperative management of the patella, postoperative patellar maltracking is minimized with lateral approaches [22,26,27,[30][31][32]34,35]. ...
... Because of the difficulty in mobilizing the patella medially, many authors have employed a tibial tuberosity osteotomy (TTO) to ease exposure [1,22,23,26,28,31,35,36]; however, the approach is still feasible without this [1,7,29,30,32,34,37]. Despite the more difficult intraoperative management of the patella, postoperative patellar maltracking is minimized with lateral approaches [22,26,27,[30][31][32]34,35]. This may, in part, be because the vastus lateralis muscle does not exhibit extensive oblique fiber arrangement distally, as compared with the distal vastus medialis [38,39], and thus, quadriceps-sparing with lateral approaches [29,30,35,37] may be more anatomically achievable than medial quadriceps-sparing approaches. ...
... Despite the more difficult intraoperative management of the patella, postoperative patellar maltracking is minimized with lateral approaches [22,26,27,[30][31][32]34,35]. This may, in part, be because the vastus lateralis muscle does not exhibit extensive oblique fiber arrangement distally, as compared with the distal vastus medialis [38,39], and thus, quadriceps-sparing with lateral approaches [29,30,35,37] may be more anatomically achievable than medial quadriceps-sparing approaches. Furthermore, because the main neurovascular supply to the anterior thigh, knee joint and patella are predominantly medial structures [7]; lateral approaches to TKA have also shown a reduction in postoperative patellar necrosis, and/or hypoesthesia [6,7,[22][23][24][25]29,34]. ...
Article
Background Lateral approaches to total knee arthroplasty (TKA) provide good surgical exposure and may provide greater ease of soft tissue balancing in patients with a valgus deformity; however, little is known about the versatility in non-valgus knees. The present study evaluated if a lateral subvastus approach can achieve adequate surgical exposure while maintaining less soft tissue damage compared with the medial parapatellar approach in knees without any significant deformity. Methods Using paired fresh-frozen cadaveric knees, the present study provides the first specimen-matched, side-by-side comparison of the lateral subvastus approach to the standard medial parapatellar approach to TKA. Ten knees were selected to undergo a lateral subvastus approach; the contralateral knee had a medial parapatellar approach as control. Incision length, surgical exposure and iatrogenic soft tissue damage were compared between the two approaches. Results The lateral subvastus approach was successfully performed using an incision length that was not different from that used in the medial parapatellar approach (p > 0.05). The resultant surgical exposure was comparable between approaches (p > 0.05). The risk of the approach included tearing of the vastus lateralis fibers, and/or abrasion of the iliotibial tract/patellar ligament. Conclusions The lateral subvastus approach to TKA provided a comparable method to the standard medial parapatellar approach. Despite adequate exposure, the approach did risk soft tissue injury. Caution needs to be exercised to reduce the risk of iatrogenic injury to the vastus lateralis and surrounding ligaments. The successful implementation in this cadaveric study substantiates the need for further consideration of this approach in clinical practice.
... Ranawat et al. [9] reported good results using a medial approach with lateral retinacular release. There were several reports which compared the clinical results between medial and lateral approach with the osteotomy of tibial tubercle [10,11]; however, superiority of the medial or lateral approach still remains controversial. To solve this problem, we prospectively compared short-term results of two approach groups. ...
... Although the rationality of the lateral approach for the valgus deformed knee has been recognized, differences in clinical results between medial and lateral approaches have been uncertain. Hay et al. [10] had randomly divided 32 patients into two groups, in one of which the lateral subvastus approach combined with a tibial tubercle osteotomy and in the other the medial parapatellar approach. And they compared the ROM, a visual analog satisfaction score, the Western Ontario McMasters University Osteoarthritis index, and the KSS at 2 years after the surgery. ...
... To avoid this eventuality, Keblish et al. [16] and Buechel [2] recommended deliberate osteotomy of the tibial tubercle. However, some complications had been reported at the osteotomy of the tibial tubercle [10,11], and postoperative rehabilitation might have to be delayed to some extent after osteotomy. Fiddian et al. [3] could evert the patella without the osteotomy of the tibial tubercle in lateral approach. ...
Article
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Introduction For the total knee arthroplasty in valgus deformed knee, superiority of the medial or lateral approach is still controversial. We compared the short-term result of two approach groups. Materials and methods Forty-seven knees in rheumatoid arthritis with valgus deformity from 6° to 24° were randomly divided into two group; medial approach (24 knees) and lateral approach (24 knees). We used Scorpio NRG PS for all knees. Median postoperative periods were 43 months in both groups. We compared the surgical time, and alignment on standing radiograph, range of motion (ROM) pre/postoperatively, and degrees of soft-tissue release procedure, and lateral laxity measured by stress radiograph immediately after operation and at final follow-up. Result Pre/postoperative alignment, surgical time, lateral laxity, and preoperative ROM had no significant in two groups; however, postoperative flexion was superior in lateral approach group 123.8°, 109° in medial approach group. All cases required iliotibial band (ITB) release at Gerdy’s tubercle, 83 % ITB at joint level, 21 % lateral collateral ligament (LCL), 17 % popliteus tendon (PT) in medial approach group, and 88 % ITB at Gerdy’s tubercle, 46 % ITB at joint level, 13 % LCL, 4 % PT in lateral approach group. Discussion In the valgus knee, lateral structures are tight. Lateral approach can directly adjust the tight structure, and also less vascular compromise to the patella than medial approach with lateral patellar release. Less invasiveness to the quadriceps muscle in lateral approach could result into better range of motion after the surgery.
... In 1991, Keblish [1] recommended a lateral parapatellar approach for knees with a fixed valgus deformity, as this method provides direct access to lateral structures, facilitating ligament balance. This technique proved to be useful in severe valgus knee deformities, promising direct exposure and release of the contracted lateral soft tissues and improvement of patellar tracking [2][3][4][5][6]. However, for many orthopaedic surgeons, the lateral approach is less familiar, and there are concerns regarding the ease of exposure and tissue coverage for closure. ...
... Patellofemoral instability is a common cause of postoperative pain and functional limitations in TKA, which [15,16]. The lateral approach may also result in improved patellar tracking in some patients following TKA [5,6,10]. Hay et al. [6] compared a medial parapatellar approach and a lateral subvastus approach with a TTO and found a significantly greater incidence of lateral patellar subluxation in the medial group (3 of 12) compared with the lateral group (0 of 16) (p=0.034). ...
... The lateral approach may also result in improved patellar tracking in some patients following TKA [5,6,10]. Hay et al. [6] compared a medial parapatellar approach and a lateral subvastus approach with a TTO and found a significantly greater incidence of lateral patellar subluxation in the medial group (3 of 12) compared with the lateral group (0 of 16) (p=0.034). The authors recommended considering a lateral approach in patients in whom problems with patella tracking were anticipated. ...
Article
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When performing total knee arthroplasty (TKA) in valgus knee deformities, a medial or lateral parapatellar approach can be performed, but the lateral approach is often considered technically more difficult. The purpose of this study was to compare intra-operative, early clinical and radiological outcomes of medial and lateral parapatellar approaches for TKA in the setting of moderate knee valgus (<10°). We prospectively analysed 424 knees with pre-operative valgus deformity between 3° and 10° that underwent TKA over an 18-year period; 109 were treated with a medial approach and 315 with a lateral approach. Intra- and post-operative outcomes and complication rates after a minimum follow-up of one year were compared. Tourniquet (p = 0.25) and surgical (p = 0.62) time were similar between groups. The popliteus tendon was released more frequently in the medial-approach group (p = 0.04), while the iliotibial band was released more frequently in the lateral-approach group (p < 0.001). A tibial tuberosity osteotomy was performed more frequently in the lateral- than medial-approach group (p = 0.003). No significant differences in limb alignment (p = 0.78), or Knee Society Score (KSS) knee (p = 0.32) and function (p = 0.47) results were noted based on surgical approach, and complication rates were similar between groups (p = 0.53). Lateral parapatellar approach is a safe and effective surgical technique for performing TKA in moderately valgus knees. These equivalent early results are encouraging for systematic use of the lateral approach in moderately valgus knees.
... This surgical procedure is primarily used for revisions, but under certain circumstances, such as valgus deformities or patellar tracking abnormalities, it could also be an alternative in primary TKA. Improved exposure as well as better controllable positioning of the femoral component has been discussed as being advantageous [4,6,10]. Moreover, the medial vastus muscle, the patellar tracking and the blood supply to the patella are preserved when performing the LSV approach combined with TTO [11]. ...
... An osteotomy of approximately 70 mm 9 30 mm 9 10 mm was performed with an oscillating saw from the lateral cortex and completed with three osteotomes to break the medial cortex (Fig. 2b). The tibial tubercle was everted on the periosteal hinge and the patella subluxed medially, allowing flexion and full exposure of the knee (Fig. 2c) [10]. Resection of the cruciates and implantation of the prosthesis were then completed as in the standard MPA. ...
... Additional surgical techniques can be necessary if the quality of surgical exposure is insufficient and the extensor mechanism in danger. In such cases, several authors advocate the lateral approach including tibial tubercle osteotomy [7,10,16,17]. ...
Article
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Purpose: The lateral subvastus approach (LSVA) with tibial tubercle osteotomy (TTO) is an alternative approach for total knee arthroplasty (TKA) in selected patients. The aim of this study was to compare clinical outcomes between LSV and medial parapatellar approaches for primary TKA and to investigate incidence of complications related to TTO. Methods: A total of 580 patients with primary TKA, meeting the inclusion criteria, were treated at our hospital from February 2006 until February 2013. All patients' data were included in the local arthroplasty register and were followed up 12 months postoperatively. The data set contains: demographic data, the WOMAC score, the KSS as well as knee flexion and complications related to tibial tubercle osteotomy. Results: The clinical outcome after TKA using the LSVA combined with TTO was comparable with those using the medial standard approach 1 year postoperatively. Four patients (3.8 %) needed a revision due to complications related to tubercle osteotomy. Conclusions: The LSVA is thus a viable alternative in cases of primary TKA if technical difficulties with the medial approach are anticipated. Applying precise surgical technique, the LSVA seems to be a safe and reproducible procedure.
... Four complications occurred in the TTO group-three tibial plateau fractures and one wound discharge [51]. A significant increase in lateral patellar subluxation in the standard medial parapatellar approach (p = 0.034) was observed [49]. Comparing the lateral with the TTO and standard medial parapatellar approach, three studies showed non-significant differences in outcomes: HSS [57], ROM, KSS [52,53,57], and VAS [52,53]. ...
... Most of the presented studies showed no significant differences between the control and experimental groups. However, pool estimates for studies in the following subgroups showed significantly increased outcomes in favor of the TTO group: ROM (p < 0.0001) [46][47][48][49][50][51][52]55,57] ...
... Twelve studies were included in the meta-analysis (Table 5) [46][47][48][49][50][51][52][53][54][55][56][57]. Follow-up ranged from 1 to 15 years; all except three studies [54,56,57] were prospective and consider TTO in both revision and primary TKA. ...
Article
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Total knee replacement (TKA) is a frequent modality performed in patients with osteoarthritis. Specific circumstances can make it much more difficult to execute successfully, and additional procedures such as osteotomy may be required. The aim of this study was to perform a meta-analysis and systematic review of osteotomies combined with TKA. Methods: In June 2022, a search PubMed, Embase, Cochrane, and Clinicaltrials was undertaken, adhering to PRISMA guidelines. The search included the terms "osteotomy" and "total knee arthroplasty". Results: Two subgroups (tibial tubercle osteotomy and medial femoral condyle osteotomy) were included in the meta-analysis. Further subgroups were described as a narrative review. The primary outcome showed no significant difference in favor to TTO. Secondary outcomes showed improved results in all presented subgroups compared to preoperative status. Conclusion: This study showed a significant deficit of randomized control trials treated with osteotomies, in addition to TKA, and a lack of evidence-based surgical guidelines for the treatment of patients with OA in special conditions: posttraumatic deformities, stiff knee, severe varus, and valgus axis or patella disorders.
... Moreover, by studying the results in two randomized groups of valgus TKAs, Sekiya et al [32] found no significant differences in range of movement (ROM), but better post-operative flexion in the group of lateral approach without TTO vs the group of medial parapatellar approach. Hay et al [62] randomly divided 32 patients in two groups, the one in which lateral subvastus approach combined with a TTO was performed and the other with classic medial approach. Between the two groups no significant differences were found in the parameters of clinical outcome (ROM, VAS score, Western Ontario McMasters University Osteoarthritis index, and KSS) at 2 years followup. ...
... Nevertheless the researchers did not support its routine use, because of the complications related with TTO and the longer surgical time (1015 min). It is not indicated in patients in whom problems with patellar tracking is anticipated [62] . ...
Research
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The majority of orthopaedic surgeons even currently agree that primary total arthroplasty in valgus knees with a deformity of more than ten degrees may prove challenging. The unique sets of bone and soft tissue abnormalities that must be addressed at the time of the operation make accurate axis restoration, component orientation and joint stability attainment a difficult task. Understanding the specific pathologic anatomic changes associated with the valgus knee is a prerequisite so as to select the proper surgical method, to optimize component position and restore soft-tissue balance. The purpose of this article is to review the valgus knee anatomical variations, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. It will also be underlying the up-to-date main approaches and surgical techniques be proposed in the English literature both for bone cuts and soft tissue management of valgus knees.
... Moreover, by studying the results in two randomized groups of valgus TKAs, Sekiya et al [32] found no significant differences in range of movement (ROM), but better post-operative flexion in the group of lateral approach without TTO vs the group of medial parapatellar approach. Hay et al [62] randomly divided 32 patients in two groups, the one in which lateral subvastus approach combined with a TTO was performed and the other with classic medial approach. Between the two groups no significant differences were found in the parameters of clinical outcome (ROM, VAS score, Western Ontario McMasters University Osteoarthritis index, and KSS) at 2 years followup. ...
... Nevertheless the researchers did not support its routine use, because of the complications related with TTO and the longer surgical time (1015 min). It is not indicated in patients in whom problems with patellar tracking is anticipated [62] . ...
Article
Full-text available
The majority of orthopaedic surgeons even currently agree that primary total arthroplasty in valgus knees with a deformity of more than ten degrees may prove challenging. The unique sets of bone and soft tissue abnormalities that must be addressed at the time of the operation make accurate axis restoration, component orientation and joint stability attainment a difficult task. Understanding the specific pathologic anatomic changes associated with the valgus knee is a prerequisite so as to select the proper surgical method, to optimize component position and restore soft-tissue balance. The purpose of this article is to review the valgus knee anatomical variations, to assess the best pre-operative planning and to evaluate how to choose the grade of constraint of the implant. It will also be underlying the up-to-date main approaches and surgical techniques be proposed in the English literature both for bone cuts and soft tissue management of valgus knees.
... The importance of concomitant re-alignment is demonstrated in early reports on patellofemoral autologous chondrocyte implantation as good outcomes were reported in only 30% of patients without corrective osteotomy [32]. Hay et al. reported a significantly greater incidence of lateral patellar subluxation post TKR with a medial approach compared with lateral approach group with tibial tubercle osteotomy [33]. Realignment procedures alone have demonstrated encouraging clinical outcomes with careful patient selection and in cases of patellar maltracking associated with chondral defects of the inferior and lateral patella. ...
Article
Full-text available
Management of patellofemoral joint pathology is challenging as a result of the unique and complex organization of static forces and dynamic factors contributing to its functional capacity. Anterior knee pain is a common musculoskeletal complaint seen daily in the practices of primary care physicians, rheumatologists, and orthopedic surgeons. The key to successful treatment lies not only in the correct diagnosis of a chondral defect, but more importantly, in the accurate identification of associated pathomechanical factors. Appreciating the pathoanatomic basis of the disease and addressing imbalances and anatomical abnormalities should guide treatment. Despite the complexity of the interplay of various components it is essential to attempt to describe patellar malalignement as a clinical entity in order to proceed with appropriate surgical management and successful outcomes. The goals of patellofemoral re- alignment surgery should be to create both a stable environment for optimal extensor mechanism performance and an appropriate load transmission for optimal cartilage wear and joint loading. In the context of this article we will review the operative management of patellofemoral malalignment; the indications for surgery, the different techniques available and the evidence regarding their effectiveness. A large number of procedures have been employed and they have all undergone various modifications over the course of the years. The majority of publications are retrospective series in poorly defined population groups. There are significant methodological inconsistencies and as a result there is lack of strong evidence base for the majority of these procedures.
... Against this background, there are a lot of comparison studies in these approaches for primary TKA in order to demonstrate which one is better. However, previous studies have mostly used non-objective and non-quantitative data such as ability of straight leg rising as an indicator of quadriceps function [11,21,23,24]. As the main intention in protecting the extensor complex is to preserve the quadriceps functions, objective criteria are needed to evaluate their function. ...
Article
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Purpose: To compare the improvement of the vastus medialis component of the quadriceps muscle electrophysiologically after the subvastus and medial parapatellar approaches in total knee arthroplasty (TKA). Methods: A total 26 patients that underwent primary unilateral in TKA were included into the study. TKAs were carried out via subvastus approach in 15 patients, while 11 patients were operated via medial parapatellar approach. The electrophysiological evaluations were carried out blindly with regard to the type of the surgical approach before the operation and at 6th week post-operatively. Non-surgical side was also evaluated as a control. Assessments were patellar tendon reflex analysis, motor unit potential analysis and interference pattern analysis (IPA) including turn-amplitude analysis and IPA during maximum contraction. Results: When they were compared to the pre-operative values, "the total mean amplitude" and "the mean turn/sec" parameters were significantly increased in group of subvastus approach (p = 0.017 and p = 0.009, respectively) at the post-operative 6th week. We would not be able to find any difference regarding the other electrophysiological parameters. There was also no significant difference between groups. Conclusion: If there was no significant difference in all the electrophysiological parameters, the increase in turn-amplitude analysis in the group of subvastus approach would be considered as an indicator of a faster functional improvement of knee extensor mechanism in these cases.
... A medial parapatellar approach was the standard approach. In cases of valgus deformity, patella baja or preoperative patella subluxation, a lateral subvastus approach with tuberosity osteotomy was used [20]. All patients received an LCS mobile-bearing prosthesis (DePuy Low Contact Stress Complete Knee System, Leeds, UK). ...
Article
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Computer-assisted surgery (CAS) for total knee arthroplasty (TKA) has become increasingly common over the last decade. There are several reports including meta-analyses that show improved alignment, but the clinical results do not differ. Most of these studies have used a bone referencing technique to size and position the prosthesis. The question arises whether CAS has a more pronounced effect on strict ligamentous referencing TKAs. We performed a prospective cohort study comparing clinical outcome of navigated TKA (43 patients) with that of conventional TKA (122 patients). Patients were assessed preoperatively, and 2 and 12 months postoperatively by an independent study nurse using validated patient-reported outcome tools as well as clinical examination. At 2 months, there was no difference between the two groups. However, after 12 months, CAS was associated with significantly less pain and stiffness, both at rest and during activities of daily living, as well as greater overall patient satisfaction. The present study demonstrated that computer-navigated TKA significantly improves patient outcome scores such as WOMAC score (P=0.002) and Knee Society score (P=0.040) 1 year after surgery in using a ligament referencing technique. Furthermore, 91% were extremely or very satisfied in the CAS TKA group versus 70% after conventional TKA (P=0.007).
... Concerns regarding a lateral skin incision have been raised due to a potential risk of haematoma when creating a larger subcutaneous medial flap. The senior author has been using a lateral skin incision in combination with a medial or lateral arthrotomy for more than 10 years, and no increased risk of wound problems was observed [12,13]. ...
Article
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Kneeling is often impaired following total knee replacement. There is no clinical study comparing a lateral to a midline skin incision with regard to kneeling. Patients with a well-functioning total knee replacement enrolled in the trial. The participants with a lateral skin incision were matched with those with a standard midline incision. Twenty-two patients were enrolled in the study: 10 had a lateral skin incision, and 12 had a midline incision. Those with a lateral skin incision had a significantly higher Forgotten Joint Score than with a midline skin incision (Difference of Means Lateral vs Midline = 10.9 [p value 0.0098]), and an improved ability to kneel at 110 degrees of flexion (Kneeling Ability Test; Difference of Means Lateral vs Midline = 41.7 [p value 0.020]). These results suggest that a lateral skin incision may provide reduced joint awareness and improved kneeling ability. Further investigation with a randomised controlled trial is needed.
... However, it should be emphasized that patient selection and proper technical procedure have a significant role in postoperative results. Similarly Hay et al. [23] compared MPA and lateral subvastus approach (LSA) with TTO in 32 patients undergoing primary TKA. Mean knee flexion, VAS, ROM and clinical scores improve significantly but there was no difference between two groups. ...
Article
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Introduction: Tibial tubercle osteotomy (TTO) is a well-established extensile approach to improve joint visualization and implant removal. Despite this, TTO is a challenging technique with a long learning curve and potential pitfalls. Complications are not infrequent, even if performing the correct surgical steps. Aim of this paper is to review the current literature about TTO, its safeness and reliability, and finally the complications rate. Materials and methods: We performed a systematic review of the available English literature, considering the outcomes and the complications of TTO. The combinations of keyword were "tibial tubercle osteotomy", "total knee arthroplasty", "total knee revision", "outcomes", "complication" and "surgical approach". Results: From the starting 322 papers available, 26 manuscripts were finally included. Most of the papers show significant improvements in clinical outcomes, both in primary and in revision procedures. Radiographic fragment healing is close to 100%. Related complications can range from 3.8-20%. Conclusion: TTO may be necessary to correct pathological tuberosity position or patella tracking. However, TTO is a challenging technique to improve the surgical approach during total knee arthroplasty. A strict surgical technique can lead to better results and to minimize complications. However, it is not clear if the improved outcome can outweigh the longer surgery and the higher risk of pitfalls.
... It was found signiicant beter patellar tracking in the group of lateral subvastus approach combined with TTO. Due to complications related with TTO and longer surgical time (10-15 min) in the lateral approach, the researchers did not support its routine use of the except for the patients in whom problems with patellar tracking were anticipated [65]. ...
... In TTO fixation, two parallel horizontal screw fixation is easy to use and has been demonstrated to result in higher stability than wire fixation under static or cyclic loadings [14,15]. However, surgeons have to adjust the screw trajectory based on the bone condition; moreover, fixation using two parallel horizontal screws is often hard to performed in revision TKA due to the interference of the tibial component [16]. To date, only two parallel horizontal screws have been used in the biomechanical testing of TTO, and no mechanical study has investigated the differences between two parallel horizontal screw configuration and other screw configurations. ...
Article
Introduction: To date, the effects of various screw configurations on the stability of tibial tubercle osteotomy (TTO) are not completely understood. Hence, the first aim of this study is to evaluate the stability of TTO under various screw configurations. The second aim is to evaluate the internal stresses in the bone and the contact forces on the bone fragment that are developed by the tibia and screws in response to the applied load after the equilibrant is revealed. Methods: To calculate the biomechanical responses of the bone and screw under loading, finite element (FE) method was used in this study. Six types of screw configurations were studied in the simulation: two parallel horizontal screws placed at a 20 mm interval, two parallel horizontal screws placed at a 30 mm interval, two parallel upward screws, two parallel downward screws, two trapezoid screws, and two divergent screws. The displacement of the bone fragment, contact forces on the fragment, and the internal stress in the bone were used as indices for comparison. Results: Among all configurations, the configuration of two parallel downward screws yielded the highest stability with the lowest fragment displacement and gap opening. Although the maximum displacement of the TTO with the configuration of two parallel horizontal screws was slightly higher than that of the downward configuration, the difference was only 0.2 mm. The configuration of two upward screws resulted in the highest fragment displacement and gap deformation between the fragment and tibia. The stress of the osteotomized bone fragment was highest with the configuration of two upward screws. Conclusion: Based on the present model, the current configuration of two parallel horizontal screws is recommended for TTO. If this is inappropriate in a specific clinical scenario, then the downward screw configuration may be used as an alternative. By contrast, the configuration of two parallel upward screws is least suggested for the fixation of TTO.
... We believe that the occurrence of complications could be effectively prevented by careful operation during surgery, protection of the surrounding soft tissue, prevention of damage to the patellar tendon, and good reduction and fixation of the tibial tubercle. 19 Tibial tubercle osteotomy is an effective way to increase total plateau exposure and help plateau reduction in bilateral tibial plateaus fracture malunion. 20,21 performed extra-articular osteotomy þ intra-articular bone grafting in patients with lateral articular surface collapse and valgus alignment. ...
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Objective: The aim of this study was to evaluate our treatment algorithm and results in revision surgery of malunited tibial plateau fracture after failure of initial treatment. Methods: Our revision strategy was as follows: First, we determined the presence of any infection. Second, we determined whether the patient required total knee arthroplasty (TKA). Third, based on the characteristics of the tibial plateau fracture malunion, patients underwent one of the following surgical methods to achieve reduction: original fracture line osteotomy, tibial tubercle + original fracture line osteotomy, fibula head + original fracture line osteotomy, and metaphyseal open window reduction rod technique. The results was assessed with healing time, Rasmussen score, knee range of motion and complication rates. Results: A total of 25 patients 16 men and 9 women; Mean age: 47.4 years (range: 35-63 years) underwent tibial plateau fracture revision operation. The time interval between the two surgeries was 2-24 months. The follow-up time was 12-30 months, and the operation time was 120-300 min. All patients received bone union at the last follow-up. The healing time was 3-6 months. The postoperative Rasmussen score was 19-29 (mean 23.8) compared with 14.4 points before the operation (p < 0.05). The postoperative knee joint activity was 60-110° (mean 95.0°), compared with 57.8° before the operation (p < 0.05). Six patients still had a 2-mm collapse on the articular surface, and 4 patients still had slight valgus (<5°). Except for 2 TKA cases, fracture reduction was excellent in 15 cases and good in 8 cases, with a good rate of 100%. Superficial wound infections occurred in 3 patients. Conclusion: Because revision of tibial plateau fracture malunion caused by failure of initial treatment is difficult, it is necessary to create a detailed surgical plan before the operation. Satisfactory clinical effects can be obtained if the correct revision strategy is used. The key to success is adopting a proper revision strategy according to the unique characteristics of the patient's tibial plateau fracture malunion. Level of evidence: Level IV, Therapeutic Study.
... For common TKA not involving a valgus deformity, Hay et al. 35 and Nikolopoulos et al. 20 identified no differences in outcomes between the medial and lateral groups at 2 years after surgery. They concluded that the lateral approach with TTO was a safe technique with comparable outcomes to the medial approach for TKA. ...
Article
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Objective To identify whether the medial or lateral approach is superior for patients with valgus knees undergoing primary total knee arthroplasty (TKA). Methods Studies evaluating the 2 approaches were sourced from the PUBMED, EMBASE, Web of Science, and OVID databases. The quality of included studies was assessed using a modified quality evaluation method, and differences between approaches were systematically reviewed. Results Seventeen observational studies were included. The studies were published between 1991 and 2016, and included 5 retrospective studies and 12 prospective studies. Sixteen evaluation methods for the study outcomes were identified. Twelve and eight complication types were identified by studies reporting the lateral and medial approaches for valgus knee, respectively. Several studies showed that pain scores and knee function were superior using a lateral approach. Conclusion The lateral approach (combined with a tibial tubercle osteotomy or proximal quadriceps snip) was more useful and safer than the medial approach in the treatment of severe uncorrectable valgus knee deformity in patients undergoing TKA. Most of the available evidence supports the use of a lateral approach provided that the surgeon is familiar with the pathological anatomy of the valgus knee.
Chapter
Bone cuts and soft-tissue releases are the principal steps in TKA. However, some knees undergoing TKA may require an additional procedure in the form of an osteotomy. An osteotomy in primary TKA is usually indicated in rigid or severe deformities to facilitate soft-tissue balance and deformity correction, to concomitantly correct an extra-articular deformity or rarely to facilitate exposure of the joint. Frequently, in varus arthritic knees undergoing TKA, the medial and posteromedial side of the tibial plateau shows adaptive changes resulting in the formation of a prominent bony flare in this area. This causes local tenting of the medial soft-tissue structures and contributes to knee deformity and medio-lateral soft-tissue imbalance. A reduction osteotomy involves excision of this medial bony flare to decompress the medial soft-tissue structures. Rarely, despite extensive soft-tissue release and a reduction osteotomy, a knee deformity may be too rigid and/or the medio-lateral soft-tissue imbalance too severe to correct. In such cases a sliding medial condylar osteotomy (SMCO) in a varus knee or a lateral epicondylar osteotomy (LEO) in a valgus knee may be required to achieve optimum limb alignment and soft-tissue balance.
Article
Background: An ideal approach for valgus knees must provide adequate exposure with minimal complications due to approach per se. Median parapatellar approach is most commonly used approach in TKA including valgus knees. A medial subvastus approach is seldom used for valgus knees and has definite advantages of maintaining extensor mechanism integrity and minimal effect on patellar tracking. The present study was conducted to evaluate outcomes of total knee arthroplasty (TKA) and efficacy of subvastus approach in valgus knees in terms of early functional recovery, limb alignment and complications. Materials and methods: We retrospectively reviewed 112 knees with valgus deformity between January 2006 and December 2011. All patients were assessed postoperatively for pain using Visual Analog Scale (VAS) and quadriceps recovery in form of time to active straight leg raising (SLR) and staircase competency and clinical outcomes using American Knee Society (AKS) score and radiographic evaluation with average followup of 40 months (range 24-84 months). Results: The mean VAS on postoperative day (POD) 1 and POD2 at rest was 2.73 and 2.39, respectively and after mobilization was 3.28 and 3.08, respectively (P < 0.001). The quadriceps recovery was very early and 92 (86.7%) patients were able to do active SLR by POD1 with mean time of 21.98 h while reciprocal gait and staircase competency was possible at 43.05 h. The AKS and function score showed significant improvement from preoperative mean score of 39 and 36 to 91 and 79 (P < 0.001), respectively, and the mean range of motion increased from 102° preoperatively to 119° at recent followup (P < 0.001). The mean tibiofemoral valgus was corrected from preoperative 16° (range 10°-35°) to 5° (range 3°-9°) valgus (P < 0.001). Conclusions: Mini-subvastus quadriceps approach provides adequate exposure and excellent early recovery for TKA in valgus knees, without increase in incidence of complications.
Article
Rationale, aims, and objectives The potential bias introduced by surgeons' lack of comparable, relevant experience when performing the procedures in different arms of randomized controlled trials (RCTs) is arguably not well‐managed or reported. The aim of this work was to review the frequency and nature with which surgeons' relevant experience is reported in RCTs of total hip (THA) and total knee arthroplasty (TKA), and to relate this to other risk of bias domains for this study design. Methods A systematic review of RCTs comparing different minimally invasive procedures for TKA and comparisons of THA and hemiarthroplasty (HA). We searched MEDLINE, EMBASE, Science Citation Index, The Cochrane Library, Conference Proceedings Citation Index‐Science (CPCI‐S), Current Controlled Trials, and Clinical Trials.gov. Results Seventy‐five relevant RCTs were identified, 65 RCTs comparing minimally invasive with standard or other minimally invasive approaches to TKA, and 10 for THA compared with HA. Risk of bias based on the reported details of surgeons' relevant experience was categorized as low, high, or unclear. There was a clear distinction before and after 2009, with a substantial decrease in trials at high or unclear risk of bias after this date. There were no strong associations between this domain and other, standard risk of bias domains for RCTs. Conclusion The surgeons' relevant experience in an evaluated procedure is often poorly reported but has improved since 2009. The variable is not adequately captured by any other risk of bias domain. Future work should concentrate on conducting research on a much larger sample of studies and in procedures other than knee and hip arthroplasty.
Article
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Randomised controlled trials are widely acknowledged as the gold standard in medical research although their validity can be undermined by non-compliance with the randomly allocated treatment and missing data. Due to the nature of the intervention, surgical trials face particular threat to compliance and data collection. For example, ineligibility for the intervention may only become apparent once the operation has commenced. It is unclear how such cases are reported and handled. The objective was to assess non-compliance and missing data in reports of trials of surgical interventions. Searches for reports of trials involving at least one surgical procedure and published in 2010 were carried out in the Medical Literature Analysis and Retrieval System Online (MEDLINE(®)). Data on missing data, non-compliance and methods of handling missing data were extracted from full texts. Descriptive data analyses were carried out on the data. Forty-five (55 %) studies reported non-compliance with treatment allocation and 52 (63 %) reported primary outcome missing data. The median levels of non-compliance and missing data were 2 % [IQR (0, 5), range (0-29)] and 6 % [IQR (0, 15), range (0-57)], respectively. Fifty-two (63 %) studies analysed as randomised, 17 (21 %) analysed per protocol and 3 (4 %) analysed as treated. Complete case analysis was the most common method used to deal with missing data, 35/52 (67 %). The reporting of non-compliance to allocation and the handling of missing data were typically suboptimal. There is still room for improvement on the use of the CONSORT statement particularly in accounting for study participants. Transparency in reporting would facilitate evidence synthesis.
Article
The lateral approach in the valgus knee asks for a lot of soft tissue releases during the arthrotomy. The hypothesis of this study was that the far medial subvastus approach could be used in valgus knees and would guarantee both functional and radiological good to excellent results. This is a retrospective study on 78 patients (84 knees) undergoing primary total knee arthroplasty (TKA) for type I or II fixed valgus knees. The mean (SD) preoperative mechanical alignment was 187° (4°) HKA angle. Functional recovery, pain, tourniquet times, necessary soft tissue releases as well as radiological alignment were measured. The Knee Score improved significantly from 45 (10) to 90 (10) (P < 0.05) and the function score improved as well from 35 (20) to 85 (10) (P < 0.05). Flexion improved from 110° (10°) to 137° (8°). Hospital stay was 4 (1.2) days. Alignment was corrected to 181° (1.5°) HKA angle with a postoperative joint line shift of +2.8 (3.2) mm. No clinical instability, as evaluated by the senior author, or osteolytic lines was observed at minimal one-year radiological follow-up. The far medial subvastus approach is an excellent approach to perform Krackow type I and II TKA with primary PS implants. LEVEL OF EVIDENCE: IV.
Article
Operationsziel Verbesserung der Zugänglichkeit zum Kniegelenk ohne übermäßige Spannung auf dem Streckapparat beim lateralen parapatellaren Zugang und beim medialen parapatellaren Zugang im Falle der Kontraktur und bei Prothesenwechseloperationen. Indikationen Ungenügende Zugänglichkeit des Kniegelenks beim lateralen parapatellaren Zugang und beim medialen parapatellaren Zugang im Falle von Kontrakturen und Prothesenwechseloperationen. Kontraindikationen Schwere periartikuläre Osteoporose oder Knochenatrophie nach Knieendoprothese sowie Vorschädigung des Patellarsehnenansatzes durch vorangegangene Eingriffe. Operationstechnik Beim lateralen oder medialen parapatellaren Zugang wird ein 8–10 cm langer Knochenblock der Tuberositas tibiae mit der oszillierenden Säge herausgelöst. Unterhalb des Tibiaplateaus wird mit dem Meißel eine Stufe erzeugt. Die Refixation erfolgt mit 2 Kortikalisschrauben, die bikortikal verankert werden. Alternativ kann bei schlechter Knochensubstanz eine Refixation mit 2 Drahtcerclagen durchgeführt werden. Weiterbehandlung Bei stabiler Refixation erfolgt die Mobilisierung unter Vollbelastung mit anliegender Streckschiene für 2–4 Wochen postoperativ mit schmerzabhängiger Steigerung der passiven unbelasteten Beugung. Bei schlechter Knochenqualität Entlastung für 6 Wochen mit schrittweiser Steigerung der Beugung um 30° jeweils 2, 4 und 6 Wochen postoperativ. Ergebnisse Von 2001 bis 2004 wurden insgesamt 67 Tuberositasosteotomien bei Prothesenwechseln mit Kontraktur oder festsitzender Tibiakomponente durchgeführt. Bei der Nachuntersuchung im Jahr 2010 bestand keine Pseudarthrose oder sekundäre Dislokation. Postoperativ war eine Revision von 2 Hämatomen und einer Hautnekrose nötig. Das Risiko der Hämatombildung und Pseudarthrose mit sekundärer Dislokation des Tuberositasfragments kann durch korrekte Operationstechnik minimiert werden.
Article
PurposeTo analyse the incidence of additional soft tissue releases with the lateral parapatellar approach, and the clinical and radiological outcomes of total knee arthroplasties performed using the lateral parapatellar approach for valgus arthritic knees. A review of the existing literature on valgus arthritic knees undergoing knee replacement was performed and our results compared.Materials and Methods This is a prospective cohort study of 50 patients operated by this approach. Operation and clinical records were assessed to determine the number and sequence of soft tissue releases. Functional outcome was measured using the Oxford Knee Score. Radiological assessment included measurement of alignment and implant positioning.Results46 patients included. Mean follow-up of 4 years. Additional lateral releases were performed in 11 (24%) cases. Mean valgus alignment corrected from 13.1 degrees pre-operatively to 5.7 degrees post-operatively. Oxford Knee Score improved from a mean pre-operative score of 11.9 to a mean post-operative score of 38.3 at final follow-up. Radiographs revealed lateralisation of the tibial component in 4 patients. No immediate or late post-operative wound complications, late instabilities or revisions were observed.Conclusion Lateral parapatellar approach is highly effective in correcting the valgus deformity with a low incidence of additional soft tissue releases. Medium-term results indicate an excellent functional outcome with no complications.
Article
PurposePatellar tracking problems represent 2–10% of complications of total knee arthroplasties (TKA) in valgus knees. However, there are no studies assessing patellar tracking according to the severity of the valgus deformity. The hypothesis was that lateral approach TKA in severe valgus deformity provides equivalent patellar tracking to that in knees with mild valgus deformity.Methods Between 1988 and 2016, 77 TKAs were performed via a lateral approach on a severe valgus deformity (HKA > 195°). Forty-three TKAs performed without tibial tubercle osteotomy and with complete radiological data were included in this study. These were compared with 86 matched TKAs performed via a lateral approach with a mild valgus deformity (HKA between 181° and 190°). Patellar tilt and patellar position were assessed by axial view radiographs at the last follow-up. Complications and clinical outcomes were also evaluated.ResultsThe follow-up was mean 52 ± 21 months in the severe valgus group. No significant differences were found between the severe valgus deformity group and the mild valgus deformity groups in patellar tilt (1.6° ± 6.6° versus 1.9° ± 3.2°, respectively) or patellar subluxation. There were complications in 12% (n = 5) and 11% (n = 9) of the severe valgus group and the mild valgus group respectively, without significant difference. There was no significant difference in extensor mechanism complication rate (2.3% versus 4.7%, respectively).Conclusion Lateral parapatellar approach, without tibial tubercle osteotomy, for TKA in severe valgus deformity results in good patellar tracking. With this approach, the extensor mechanism complication rate in severe valgus deformity was not higher than for mild valgus deformity.Level of evidenceIII.
Tibial tubercle osteotomy facilitates access to the knee joint without excessive tension of the extensor apparatus with the lateral parapatellar approach and the medial parapatellar approach in case of contracture or revision arthroplasty. Inadequate exposure of the knee joint with the lateral parapatellar approach and inadequate exposure of the knee joint with the medial parapatellar approach in case of contracture and revision arthroplasty. Severe periarticular osteoporosis or bone atrophy after knee arthroplasty and damage to the patella tendon insertion due to previous operations. A bone block 8-10 cm long is excised with the tibial tubercle using an oscillating saw. A step cut inferior to the tibial plateau is created with a chisel. Refixation is performed with two cortical screws. Alternatively, in case of poor bone quality, refixation is accomplished with two cerclage wires. In case of stable refixation, full weight bearing is allowed with an extension brace for 2-4 weeks and passive flexion is increased as tolerated. In case of poor bone quality, it is recommended that full weight bearing be postponed for 6 weeks, whereby full flexion is regained in 30° steps at 2, 4, and 6 weeks postoperatively. From 2001-2004, 67 osteotomies of the tibial tubercle were performed for revision arthroplasty. During follow-up in 2010, no pseudarthrosis or dislocation was noticed. Postoperatively, two hematoma and one skin necrosis had to be revised. The risk of hematoma and pseudarthrosis or dislocation of the fragment can be minimized by using the correct operative technique.
Article
Résumé Une bonne course rotulienne est nécessaire pour que le résultat fonctionnel d’une prothèse totale de genou (PTG) soit satisfaisant. Elle dépend de nombreux facteurs. L’objectif de cette étude est d’identifier les facteurs principaux qui impactent la course patellaire et de savoir comment les maîtriser pour obtenir une course patellaire optimale : le dessin de la trochlée prothétique, plus ou moins favorable (« patella friendly ») : elle doit être évaluée précisément et il faut choisir une prothèse ayant une trochlée favorable ; le dessin de la pièce patellaire ; le type d’implant tibial utilisé ; la voie d’abord et la gestion des structures anatomiques péri-patellaires incluant d’éventuels gestes de libération latérale ; les coupes fémorales (distale et postérieures) qui conditionnent l’alignement fémoro-tibial, la rotation de l’implant fémoral et la hauteur patellaire ; la rotation de l’implant tibial par rapport à la tubérosité tibiale antérieure ; les caractéristiques de la coupe patellaire, en cas de resurfaçage. En cas d’instabilité ou de mauvaise course patellaire, et en l’absence de malposition prothétique, 2 principales techniques chirurgicales ont été décrites : la reconstruction du MPFL et la médialisation de la tubérosité tibiale antérieure. Elles doivent être associées à la correction des autres facteurs (dessin de la trochlée prothétique, coupes fémorales distales et postérieures, positionnement de l’implant tibial, forme et position de la pièce patellaire, etc.) , essentiels pour obtenir une course patellaire optimale.
Article
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We have investigated the reliability of the American Knee Society Score (AKS), a widely used functional outcome score for knee arthroplasty. 29 subjects were assessed in random order by 6 observers, each patient seen twice by each observer. The interobserver reference intervals were 16 points for the Knee Score (0-100 points) and 21 points for the Function Score (0-100 points). The intraobserver reference intervals were smaller, 11 points and 13 points for the Knee Score and the Function Score, respectively. The presence of arthritis in other joints and general debility did not affect the reliability of the scores. The more experienced observers had greater intraobserver reproducibility. Notably, we found moderate agreement between observers in the subjective variables, while the objective variables produced lower levels of agreement. The high inter- and intraobserver variations of the AKS makes estimation of score change questionable. Reliable use of the AKS would necessitate repeated evaluation by an experienced observer.
Article
Objectives Simple standard approach to the knee for implantation of a total knee prosthesis. IndicationsInsertion of a total knee prosthesis. ContraindicationsExisting scars from medial or lateral approaches to the knee. The distance between old scar and planned incision should never be less than 5 cm. Surgical TechniqueLateral parapatellar approach with judicious detachment of the iliotibial tract from Gerdy’s tubercle. Opening of the compartment of tibialis anterior muscle. Mobilization of the patellar ligament together with Hoffa’s fat pad in a medial direction. Osteotomy of the tibial tuberosity. Retraction of the distal part of the quadriceps, the patella, the patellar ligament and the tibial tuberosity medially, taking care not to detach the soft tissue from the medial side of the tuberosity. After insertion of the components refixation of the tibial tuberosity with two 3.5-mm cortical screws using the lag screw principle. Postoperative CareUnrestricted functional treatment possible starting day 1. ResultsSince 1990 we implanted 702 total knee prostheses using the described approach. In 99% of the patients the osteotomy consolidated during the first 3 months without formation of a callus. Complications attributable to the osteotomy of the tuberosity were encountered in 7 patients (1%).
Article
Objectives Simple standard approach to the knee for implantation of a total knee prosthesis. Indications Insertion of a total knee prosthesis. Contraindications Existing scars from medial or median approaches to the knee. The distance between old scar and planned incision should never be less than 5 cm. Surgical Technique Lateral parapatellar approach with judicious detachment of the iliotibial tract from Gerdy's tubercle. Opening of the compartment of tibialis anterior muscle. Mobilization of the patellar ligament together with Hoffa's fat pad in a medial direction. Osteotomy of the tibial tuberosity. Retraction of the distal part of the quadriceps, the patella, the patellar ligament and the tibial tuberosity medially, taking care not to detach the soft tissue from the medial side of the tuberosity. After insertion of the components refixation of the tibial tuberosity with two 3.5-mm cortical screws using the lag screw principle. Postoperative Care Unrestricted functional treatment possible starting day 1. Results Since 1990 we implanted 702 tokal knee prostheses using the described approach. In 99% of the patients the osteotomy consolidated during the first 3 months without formation of a callus. Complications attributable to the osteotomy of the tuberosity were encountered in 7 patients (1%).
Article
The X-ray technique for the tangential visualization of the patellofemoral joint is described; 3 X-ray signs (patellofemoral angle, patellofemoral index and patellofemoral displacement) are proposed as diagnostic aids in cases of subluxation of the patella and chondromalacia patellae. Theoretically, the pathogenesis of chondromalacia patellae and patellofemoral osteoarthritis may be explained as manifestations of cartilage damage secondary to lateral patellofemoral hyperpressure and medial patellofemoral hyperpressure.
Article
Valgus deformity correction poses a major challenge in total knee arthroplasty (TKA). The standard medial approach has many technical limitations and disadvantages that include patellofemoral maltracking and subsequent patellar problems. The lateral approach has been developed and utilized successfully in 79 cases (53 with over two-year follow-up evaluation) since 1980. The biomedical rationale of the approach is sound, and addresses the pathologic anatomy of fixed valgus deformity. Surgical technique is direct, anatomical, more physiologic, and maintains soft-tissue integrity. The "lateral release" is performed as part of the approach. Patellofemoral tracking and alignment stability are optimized and medial blood supply preserved. Clinical experience has shown the approach to be more aesthetic and results objectively superior. Scores have been good/excellent in 94.3% of cases. Knee stability is enhanced with the use of nonconstrained prostheses in this difficult group of patients. The lateral approach is recommended as the "approach of choice" for fixed valgus deformity in TKA.
Article
The cases of twenty-four patients who had twenty-six osteotomies of the tibial tubercle in conjunction with total knee replacement were analyzed with regard to complications and technical considerations. The patients were followed for a minimum of two years (average, three years and six months). Major complications related to the surgical technique occurred in 23 per cent of the knees and complications not related to the technique, in an additional 8 per cent. Rheumatoid arthritis and a history of at least one previous operation about the knee were predisposing factors for these complications.
Article
Arterial blood supply of the patella was demonstrated in 21 cadaver knees by intraarterial injection of radiopaque contrast. When the standard medial parapatellar approach or lateral retinacular release was carried out at a distance of at least 1 cm from the margin of the patella, some steps in total knee arthroplasty caused no impairment and others jeopardized the filling of intraosseous vessels. The radial intraosseous vessels are jeopardized by osteotomy of a deformed patella or excision of fat pad. The prepatellar vessels greatly contribute to intraosseous vascularization and should be carefully preserved.
Article
A prospective clinical and radionuclide study was done to ascertain the effect of a lateral release on patella vascularity in total knee arthroplasty. Although the basic surgical procedure was the same in all 36 knees, postoperative technetium bone scans revealed a higher incidence (9 of 16, 56.4%) of vascular compromise in knees with a lateral release than in those without a lateral release (3 of 20, 15%). Although only one clinical complication (fractured patella not requiring secondary surgery) occurred, the lateral release itself appears to have a causal relationship with patella viability. It does not seem to be the sole determinant, however, because the development of a "cold" patella in three knees that did not have a lateral release implicates other factors, such as thermal necrosis and anatomic variation of the blood supply.
Article
Exposure with an extended tibial tubercle and tibial crest osteotomy was done for 136 total knee arthroplasties from 1986 to 1994: There were 26 primary arthroplasties, 76 revision, 10 repeated revision, 19 infected, and 5 repeated revision for infection. Adequate exposure was achieved and further release of the quadriceps mechanism was not necessary. Two or 3 wires were passed through the lateral edge of the tibial tubercle and through the medial tibial cortex to reattach the bone fragment and patellar tendon. Mean range of motion in these cases at 2 years after surgery was 93.7 degrees (range, 15 degrees-140 degrees). Two knees had extension lag, unchanged from their preoperative condition. Two tibial tubercles had partial proximal avulsion fracture, but did not separate widely. No evidence of non-union occurred in the simple cases or in the infected cases in which repeat elevation of the tibial tubercle flap and quadriceps mechanism was done. Three wires were removed because of pain. Two tibial fractures occurred in a single patient with diabetic Charcot arthropathy, and in 1 with manipulation after open adhesiolysis. Quadriceps function was not compromised in any case. Knees with Charcot arthropathy may need prolonged protection from weightbearing. Special caution should be exercised when manipulation is done to improve knee flexibility.
Article
The rate of lateral retinacular releases in 2 groups of patients who underwent knee surgery performed by the senior author is compared and the factors that contribute to these differing rates are discussed. The first group of subjects consists of 88 patients who had total knee arthroplasties performed with a standard medial parapatellar approach between August 1987 and August 1988. The second group is comprised of 88 patients who had total knee arthroplasties through a midvastus surgical arthrotomy that splits the fibers of the vastus medialis muscle. This method is used by the senior author for all primary total knee arthroplasties. Lateral retinacular releases were performed in 50% of the cases in the medial parapatellar group versus only 3% of the cases in the midvastus group. Patellofemoral instability occurs as a consequence of incising the quadriceps tendon in the medial parapatellar approach and results in the need to perform lateral retinacular releases. The reduction in lateral retinacular releases is attributed to the fact that the midvastus approach leaves the connection of the vastus medialis to the quadriceps tendon intact.
Article
In a prospective study of 51 patients (61 cases) with primary total knee arthroplasty (valgus knees and/or knees that had undergone previous nonarthroplasty surgery), a lateral approach with osteotomy of the tibial tubercle was performed. In a lateral approach, lateral release techniques form part of the approach. In addition, the medial blood supply to the patella is preserved. An additional tibial osteotomy grants wide exposure with little tension on the extensor mechanism during eversion of the patella. The patients were followed up clinically (51 patients, 61 cases) and radiologically (44 patients, 52 cases) for 1 year. No postoperative tibial fractures, no delayed unions, and no nonunions at the site of the osteotomy were seen. No patellar necrosis occurred. The results after 1 year were good or excellent in 45 (88%) patients, fair in four (8%), and poor in two (4%). Complications related to technique were hematoma (four patients) and compartment syndrome (one patient). These complications occurred early in the series and were eliminated by technical modifications.
Article
Tibial tubercle osteotomies currently are used as an exposure technique for revision total knee arthroplasty and for distal patellofemoral realignment. A review of the literature reveals no biomechanical studies that evaluate methods of osteotomy fixation in terms of static strength. This study evaluates the fixation strength of common techniques used to repair tibial tubercle osteotomies. Bevel and stepcut tibial tubercle osteotomies were created in 36 anatomic specimen knees and were repaired with either two 4.5-mm cortical screws or 18-gauge stainless steel cerclage wire. The failure load for the bevelcut osteotomies repaired with two-screws was 1,654 +/- 359 N; for the bevelcut osteotomies repaired with three cerclage wires, 622 +/- 283 N; for the stepcut osteotomies repaired with three cerclage wires, was 984 +/- 441 N; and for the stepcut osteotomy repaired with four cerclage wires, 1,099 +/- 632 N. This study shows that two bicortical screws provide the greatest static fixation strength for repairing tibial tubercle osteotomies. When repairing tibial tubercle osteotomies for distal patellofemoral realignment, screw fixation would provide the most reliable fixation. However, the placement of screws around the stem of a revision arthroplasty tibial component is difficult. Cerclage wires are easier to place and provide solid static fixation, especially with the addition of a proximal stepcut osteotomy.
Article
Patella complications are recognized sequelae of total knee arthroplasty (TKA). Disruption of blood flow to the patella and adjacent soft tissues during surgery may contribute to reduced viability of the bone and patella ligament tissue. The effect on genicular blood flow to the medial and lateral patella was compared for a medial (MA) and lateral arthrotomy (LA) during TKA. Laser Doppler flowmetry was used to measure both baseline and postarthrotomy flow in vivo for 16 primary TKA patients. Flow in the lateral patella was reduced approximately 20% for both MA and LA. Conversely, the use of MA resulted in substantial reduction in flow to the medial patella (53%) compared to the lateral approach (27%). A large standard deviation of scores was evident in all cases. Although there was a tendency for LA to disturb the patellar blood flow less, the difference was not significant. It was concluded that neither approach is superior regarding the blood flow preservation to the patella. Hence, a lateral approach might only have an advantage in knee joints that are likely to need a lateral release in combination with an MA-e.g., a valgus deformity or preoperative patella maltracking.
Article
Tibial tubercle osteotomy (TTO) is a recognized technique for improving exposure when performing total knee arthroplasty surgery. Forty-two patients were reviewed at a mean of 8 years after TTO. Preoperatively, mean extension was 8 degrees +/- 14 degrees , mean flexion 74 degrees +/- 30 degrees , and Knee Society score 73 +/- 37. At latest follow-up, mean extension was 4 degrees +/- 15 degrees , mean flexion 91 degrees +/- 22 degrees , and Knee Society score 124 +/- 42.6 (P < or = .0001). Seventy-three percent of patients had an excellent/good score at latest follow-up. Twenty-five percent of patients experienced no extensor lag, and 66% of extensor lags had resolved within 6 months. Mean time for osteotomy union was 14 weeks. In this series, TTO performed to enhance surgical exposure did not adversely affect the outcome after total knee arthroplasty but resulted in serious complications in 5% of patients.
Article
Intraoperative lateral retinacular release performed during primary total knee arthroplasty (TKA) can improve patellar tracking. This study compares the outcomes of patients who did and did not have lateral retinacular release during primary TKA. One thousand one hundred eight consecutive primary TKAs were reviewed. Lateral release was performed on 314 patients; 794 patients did not undergo release. Comparisons of range of motion, Knee Society Score, and postoperative complications were made between the 2 groups. At an average follow-up of 4.7 years, no statistically significant difference in range of motion, Knee Society Score, or postoperative complications of patella fracture, subluxation, postoperative manipulation, or wound complications was demonstrated. Lateral retinacular release to achieve improved patellar tracking does not compromise the clinical outcomes or complication rate of primary TKA.